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San Joaquin County <br /> Environmental Health Department oen <br /> ^ Donna Horannsxu <br /> East Street <br /> Stock �, ���|���mm�� �����~���� p*osn�mcomeo�xn�*u <br /> �x <br /> nmmrtmooxu/"" nsHu <br /> ------- --'-'--------- -------'--- —� Jeoc°""e,m`.nexo.no/ <br /> Website: vwm���0oum,g�hd <br /> --~— <br /> Phone: (209)488'3420 �-0��da �'--'�a�� <br /> Fax: (289)4S4'0138 � �.� 9 H=� <br /> @[V 2 12017 <br /> APPLICATION ����� U�JF����o�����N�JF� �T�������� T��J�� <br /> , ^' ' ,_'��, " ' '~�', FOR^ ^�,~��^_' ^��/ ^��^�,��� STORAGE��' ~,^���_ / ��,�,^ <br /> RETROFIT ORPIPING REPAIR PERM—IYIRONMENTAL HEALTH <br /> DEPARTMENT <br /> [] 1. Submit all infunnuhnn in triplicate. Answer all questions, leaving no blanks. One copy will be returned to <br /> the applicant with comments. <br /> [] 2. Include a detailed site map on a separate sheet ofpaper showing all work to be done. Include the location <br /> of the tanks(n), piping, all tank-related oppurtenunoom, ntroots, adjacent properties (north toward the top of the <br /> pogo), nearby septic tanks, |uaohfie|ds, water wells, bui|dingo, underground public utility lines(including wm\er, <br /> sanitary sewer and aVonn uowor), and distance of piping from tank to dispensers. If underground utilities are <br /> not included on the site map, you must state in writing that USA Dig will be oonCeoVod prior to excavation <br /> activities. <br /> [] 3. Complete pages 3'6 "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT". �If sampling is required, sampling firm shall be an independent third party from the <br /> contractor performing the work. <br /> [] 4. Complete page 7. "Authorization to Release". This form must be signed and dated by the <br /> OVVNERIOPERATORofthe facility. <br /> [] 5. Submit completed "Service Request"form and "Underground Storage Tank Program Fee Worksheet". <br /> [] 8. If performing any excavation auUviUeo, and the facility is located outside of the city |imito, submit a "Backfill <br /> Excavation Certificate" as required by the San Joaquin County Building Department. If o "Backfill <br /> Excavation Certificate" is required by any incorporated areas (cities), submit tnthe appropriate City Building <br /> Oepertmonto, pursuant to the Uniform Building Code STD 70'11. <br /> [] 7. The maximum review time for Plan Review is 15 working days from receipt of the adeguately completed <br /> plan. If gross deficiencies are identified, an addendum will be required with a $132.00 per hour fee and the <br /> review will begin onthe date ofresubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the Environmental <br /> Health Departmment (EHD)' <br /> [] O' Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) <br /> atmosphere and oxygen |eve|), adequate number(s) and appropriate type(n) of fire oxdnguishor(s), and <br /> barriers tosecure the area as necessary to minimize traffic and pedestrian interference. It shall bathe project <br /> manager's responsibility for compliance with all health & safety regulations and requirements, including <br /> confined space nequivomentn, which shall be strictly adhered to at all times during the oounoo of the <br /> underground storage tank(UST)activities. <br /> [] 10. The EHO permit shall be on site during all USTpennit'ne|ated activities. <br /> [] 11. Any changes in this document nhoU be approved by the EHO prior to initiating work. All changes to any <br /> work must bodescribed in detail on pages 3 &4and be shown onthe detailed site mop. <br /> 1 <br />